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Review

Question 1 of 50

1. Question

A 75-year-old woman has been brought to the casualty department by a ‘blue light’ ambulance after being discovered at home by a concerned neighbour. She has been seen by a casualty officer who has diagnosed a CVA with right hemiparesis and dysphasia and has referred her onto the medical team on call.

The only medical history available is that from the neighbour who says that the patient is known to have suffered from an irregular pulse. She does not appear to be on any medications. The patient is in sinus rhythm, with the remainder of her general examination being normal.

Several routine bloods are requested on the patient to determine the cause of her previous irregular pulse and CVA. After a few days,the thyroid function tests come back and show:

TSH 0.2 mU/l (0.4–5)

plasma T4 144 nmol/l (58–174)

T3 2.71 nmol/l (1.07–3.18)

What would be the classification of her thyroid status?

Subclinical hyperthyroidism

Overt thyrotoxicosis

Physiological change in thyroid hormone status associated with old age

Euthryoid

Subclinical central hypothyroidism

Correct

Subclinical thyrotoxicosis is defined by the presence of a low serum thyrotrophin (TSH) concentration in an asymptomatic patient with normal serum free thyroxine (T4) and triiodothyronine (T3) concentrations .

Incorrect

Subclinical thyrotoxicosis is defined by the presence of a low serum thyrotrophin (TSH) concentration in an asymptomatic patient with normal serum free thyroxine (T4) and triiodothyronine (T3) concentrations .

Question 2 of 50

2. Question

A 60-year-old lady has been referred to the endocrine clinic with a history of increasing shoe size and problems with her dentures fitting. She also complains of flushing and sweating.

Because of a suspected diagnosis of acromegaly, an oral glucose tolerance test with growth hormone is performed which was poven to be positive for acromegaly , as well as a gadolinium-enhanced magnetic resonance image (MRI) of the pituitary which is reported as normal.

Which two steps would you take next to best manage her case?

CT of the chest and abdomen

Chromogranin A

Arginine test

Computerised tomography (CT) of the pituitary

Refer for transphenoidal hypophysectomy

Insulin tolerance test

Visual field testing

Inferior petrosal vein sampling

Correct

The oral glucose tolerance test shows non-suppression of growth hormone (GH) secretion with the 75 g glucose load indicating the diagnosis of acromegaly. However the magnetic resonance image (MRI) of the pituitary is normal which is unusual, as acromegaly is usually caused by a pituitary macroadenoma. This raises the possibility of other causes of acromegaly.

The patient complains of flushing, which is a symptom of carcinoid syndrome. Carcinoid tumours can rarely produce gonadotrophin-releasing hormone (GnRH), causing pituitary hyperplasia and acromegaly.

CT of the chest and abdomen would look for a carcinoid tumour and chromogranin A is a blood marker for carcinoid tissue.

Incorrect

The oral glucose tolerance test shows non-suppression of growth hormone (GH) secretion with the 75 g glucose load indicating the diagnosis of acromegaly. However the magnetic resonance image (MRI) of the pituitary is normal which is unusual, as acromegaly is usually caused by a pituitary macroadenoma. This raises the possibility of other causes of acromegaly.

The patient complains of flushing, which is a symptom of carcinoid syndrome. Carcinoid tumours can rarely produce gonadotrophin-releasing hormone (GnRH), causing pituitary hyperplasia and acromegaly.

CT of the chest and abdomen would look for a carcinoid tumour and chromogranin A is a blood marker for carcinoid tissue.

Question 3 of 50

3. Question

A 42-year-old Portuguese woman presents to her GP with increasing lethargy. He had seen her twice in the past few months and commenced antidepressants at her last appointment. Most recently she had been complaining of increasing nausea and vomiting and lost a considerable amount of weight.

On examination her blood pressure was 95/65 mmHg and her BMI was 21.

Investigations:

Na 126 mmol/l

K 4.8 mmol/l

TSH 7 mU/l (0.4–5)

Free T4 7 pmol/l (10–22)

Urea 10.1 mmol/l

Hb 10.1 g/dl (normochromic, normocytic),eosinophil count raised

Which of the following is the most likely cause of her adrenal insufficiency?

Autoimmune adrenalitis

Tuberculosis

Adrenal infarction

Secondary malignancy

Amyloidosis

Correct

Autoimmune adrenalitis is the commonest cause of primary adrenal insufficiency and there is evidence of hypothyroidisim.

Incorrect

Autoimmune adrenalitis is the commonest cause of primary adrenal insufficiency and there is evidence of hypothyroidisim.

Question 4 of 50

4. Question

You review a 28-year-old woman with Hashimoto’s thyroiditis in the thyroid clinic. She has been stable on 100 μg of thyroxine for the past few years and recent TSH was measured at 1.0 mU/l some 6 months ago (normal range 0.4–5). The reason for this appointment is that she is 12 weeks pregnant.

She is concerned about increased risk of spontaneous abortion. Which of the following most accurately quantifies the risk for her?

There is a twofold increase in risk

There is an eightfold increase in risk

There is a threefold increase in risk

There is no increase in risk

There is a fourfold increase in risk

Correct

In patients with positive thyroid autoantibodies there is a twofold increased risk of spontaneous abortion.

In patients who are suboptimally treated for hypothyroidism there is a 21% risk of pregnancy induced hypertension. Maternal hypothyroidism is also associated with increased risk of pregnancy induced anaemia and postpartum haemorrhage.

Incorrect

In patients with positive thyroid autoantibodies there is a twofold increased risk of spontaneous abortion.

In patients who are suboptimally treated for hypothyroidism there is a 21% risk of pregnancy induced hypertension. Maternal hypothyroidism is also associated with increased risk of pregnancy induced anaemia and postpartum haemorrhage.

Question 5 of 50

5. Question

A 23-year-old final year medical student presents to the student health service complaining of increased hairiness and trouble with acne. Her periods are erratic and she is an intermittent user of the oral contraceptive pill.

Which of the following is the investigation most likely to confirm the diagnosis in this case?

Transvaginal ultrasound scan

Pituitary MRI

17-OH progesterone levels

Adrenal ultrasound scan

Karyotyping

Correct

This patient’s clinical picture is suggestive of polycystic ovarian syndrome (PCOS) and transvaginal ultrasound is said to have 91% diagnostic sensitivity for the condition in experienced hands.

Incorrect

This patient’s clinical picture is suggestive of polycystic ovarian syndrome (PCOS) and transvaginal ultrasound is said to have 91% diagnostic sensitivity for the condition in experienced hands.

Question 6 of 50

6. Question

A 32-year-old man presents for review. He has told his general practitioner (GP) that he consumes up to 8 or 9 l of drinks per day and is constantly up during the night and day to pass urine.

The GP has checked some routine bloods; a fasting blood sugar is 3.4 mmol/l. You arrange a water deprivation test. Maximal serum osmolality during the test reaches 290 mOsmol/kg and urine osmolality after fluid deprivation reaches 830 mOsmol/kg with no significant change after desmopressin.

7. Question

An overweight 68-year-old woman with a five-year history of type-2 diabetes mellitus attends for her annual review. She is currently being treated with metformin 2 g total daily dose.

The following investigations are performed:

HbA1C 11.2%

urea 14.2

creat 240

cholesterol 7.5

Which of the following represents the most appropriate therapeutic option for this patient?

start insulin and stop metformin

start gliclazide instead of metformin

start gliclazide in addition to metformin

start insulin and continue metformin

start a statin

Correct

This patient has renal failure and as such metformin is contraindicated. In addition her HbA1c is out of control at 11.2%. It is highly unlikely that gliclazide would achieve the necessary level of glycaemic control and as such initiation of insulin therapy is the most appropriate therapeutic option.

Incorrect

This patient has renal failure and as such metformin is contraindicated. In addition her HbA1c is out of control at 11.2%. It is highly unlikely that gliclazide would achieve the necessary level of glycaemic control and as such initiation of insulin therapy is the most appropriate therapeutic option.

Question 8 of 50

8. Question

You review a 46-year-old man who complains of polydipsia and polyuria. On dipstick urine testing there are 2+ of glucose.

Which of the following would best explain these findings?

Glucagonoma

Insulinoma

Head Injury

Hypothyroidism

Hyperparathyroidism

Correct

Head injury is more likely to be a cause of diabetes insipidus rather than diabetes mellitus, hyperthyroidism is associated with diabetes mellitus and hyperparathyroidism may be associated with diuresis related to hypercalcaemia.

Insulinoma presents with collapse due to hypoglycaemia; this leaves glucagonoma as the most likely answer here.

Incorrect

Head injury is more likely to be a cause of diabetes insipidus rather than diabetes mellitus, hyperthyroidism is associated with diabetes mellitus and hyperparathyroidism may be associated with diuresis related to hypercalcaemia.

Insulinoma presents with collapse due to hypoglycaemia; this leaves glucagonoma as the most likely answer here.

Question 9 of 50

9. Question

A 72-year-old man presents to the endocrine clinic for review. He has been taking amiodarone for the past few months for paroxysmal atrial fibrillation. During the past 2 months he has noticed weight loss and heat intolerance, with a return of short runs of irregular heart beat.

In contrast, AIT type 2 is thought to result from a direct toxic effect of amiodarone and is associated with increased radioiodine uptake on thyroid scan and raised IL-6 levels. In both cases, amiodarone should be discontinued if possible.

Treatments differ in that type 1 is usually treated with a combination of antithyroid drugs and potassium perchlorate therapy, whereas type 2 is usually treated with a combination of antithyroid drugs and corticosteroids such as prednisolone.

In contrast, AIT type 2 is thought to result from a direct toxic effect of amiodarone and is associated with increased radioiodine uptake on thyroid scan and raised IL-6 levels. In both cases, amiodarone should be discontinued if possible.

Treatments differ in that type 1 is usually treated with a combination of antithyroid drugs and potassium perchlorate therapy, whereas type 2 is usually treated with a combination of antithyroid drugs and corticosteroids such as prednisolone.

Question 10 of 50

10. Question

A 16-year-old hirsute, obese lady is referred to your clinic with a prolactin of 850 mU/l.

What is your next management step?

Pregnancy test

Serum 17-hydroxy-progesterone

MRI of the pituitary

Serum testosterone

Serum FSH and LH

Correct

The first test to do when seeing anyone with hyperprolactinaemia is to exclude pregnancy, as it is the most common cause.

Obesity and hirsutism are common and may not indicate any underlying pathology. Prolactin is normally less than 450 mU/l. It can rise tenfold in pregnancy.

Incorrect

The first test to do when seeing anyone with hyperprolactinaemia is to exclude pregnancy, as it is the most common cause.

Obesity and hirsutism are common and may not indicate any underlying pathology. Prolactin is normally less than 450 mU/l. It can rise tenfold in pregnancy.

Question 11 of 50

11. Question

A 17-year-old boy presents for review with concerns about his sexual function. He has recently begun a relationship with a girl and is unable to become sexually aroused. Past history of note includes repair of cleft lip and palate.

On examination he is normal height and is thin. He has failure of development of secondary sexual characteristics.

Investigations

TSH normal

LH,FSH both low

Testosterone low

Which of the following is the most likely diagnosis in this case?

Kallman's syndrome

Previous mumps infection

Congenital adrenal hyperplasia

Prader–Willi syndrome

Klinefelter’s syndrome

Correct

This youth has secondary hypogonadism as a result of failure of episodic GnRH secretion. This results from disordered migration of GnRH-producing neurones to the hypothalamus.

It has an incidence of 1 in 10,000 males with a male to female ratio of 4:1. Anosmia is present in 75% and there is an increased association with cleft lip and palate.

Incorrect

This youth has secondary hypogonadism as a result of failure of episodic GnRH secretion. This results from disordered migration of GnRH-producing neurones to the hypothalamus.

It has an incidence of 1 in 10,000 males with a male to female ratio of 4:1. Anosmia is present in 75% and there is an increased association with cleft lip and palate.

Question 12 of 50

12. Question

A 58-year-old lady presents with a week’s history of malaise and neck pain. On examination: P125 BP132/74. She has a fine tremor and lid lag. Examination of her neck reveals an enlarged tender thyroid.

Biochemistry results:

T4 40 nmol/l

TSH < 0.01 mU/l

ESR 40 mm/h

The most likely diagnosis is:

Subacute thyroiditis

Toxic multinodular goitre

Graves’ disease

Toxic solitary nodule

Medullary carcinoma of the thyroid

Correct

This is a description of Subacute (De Quervain’s) thyroiditis, which usually presents with malaise and neck pain. The neck pain can radiate to the ear or occiput. There is often tenderness and nodularity of the thyroid.

ESR is often elevated. 99mTechnetium scan shows no technetium uptake by the thyroid.

Incorrect

This is a description of Subacute (De Quervain’s) thyroiditis, which usually presents with malaise and neck pain. The neck pain can radiate to the ear or occiput. There is often tenderness and nodularity of the thyroid.

ESR is often elevated. 99mTechnetium scan shows no technetium uptake by the thyroid.

Question 13 of 50

13. Question

A 25-year-old woman presents with palpitations with atrial fibrillation on her ECG. She is 4 days postpartum and is currently breast-feeding. Her daughter is very healthy. She has no past medical history.

On examination, she has a palpable smooth thyroid goitre with a bruit.

Which one of the following is the most likely diagnosis of her goitre?

Graves’ disease

Struma ovarii

Riedel’s thyroiditis

Postpartum thyroiditis

Pregnancy

Correct

The patient is clinically hyperthyroid; therefore, the cause of the goitre is not likely to be pregnancy or Riedel’s thryroiditis (a chronic fibrotic hard goitre that is usually euthyroid or sometimes hypothyroid). Struma ovarii is caused by ectopic thyroid tissue, so there is no goitre present.

Postpartum thyroiditis usually occurs 2–12 months after birth and may present with a goitre, but very rarely is there a bruit.

Incorrect

The patient is clinically hyperthyroid; therefore, the cause of the goitre is not likely to be pregnancy or Riedel’s thryroiditis (a chronic fibrotic hard goitre that is usually euthyroid or sometimes hypothyroid). Struma ovarii is caused by ectopic thyroid tissue, so there is no goitre present.

Postpartum thyroiditis usually occurs 2–12 months after birth and may present with a goitre, but very rarely is there a bruit.

Question 14 of 50

14. Question

A 45-year-old woman was referred by her GP for the management of her type 1 diabetes and persistent hypertension. In addition to insulin for her diabetes she was also on sertraline and alprazolam for her depression and carbamazepine for her agonizing postherpetic neuralgia.

On examination she was obese with a round face and moderate facial acne. She was a heavy drinker. An overnight dexamethasone suppression test showed failure of suppression of cortisol. A provisional diagnosis of Cushing’s syndrome was made. However, computed tomography (CT) of the abdomen revealed normal adrenal glands and the serum cortisol measurement showed normal daily variation.

Further investigations including a midnight cortisol later excluded Cushing’s syndrome.

What was the reason for her failed initial dexamethasone suppression test?

The compounding effect of alcohol and carbamazepine on the cytochrome P-450 system

Fluctuating level of adrenocorticotropic hormone (ACTH) and cortisol due to non-compliance with insulin treatment

Ectopic ACTH production

Interference of metformin with the cortisol radioimmunoassay

Variance of baseline cortisol due to fluctuating glycemic control

Correct

The overnight dexamethasone suppression test is usually used as a screening test for Cushing’s syndrome. This test has a falsepositive rate of up to 2–12%, Dexamethasone is primarily metabolised by the cytochrome P-450 system.

Considerable increases in cytochrome P-450 enzymes can be seen in regular smokers and people who drink alcohol regularly

Incorrect

The overnight dexamethasone suppression test is usually used as a screening test for Cushing’s syndrome. This test has a falsepositive rate of up to 2–12%, Dexamethasone is primarily metabolised by the cytochrome P-450 system.

Considerable increases in cytochrome P-450 enzymes can be seen in regular smokers and people who drink alcohol regularly

Question 15 of 50

15. Question

A 25-year-old female patient is attending clinic for follow-up. She has a background of McCune–Albright syndrome, which had been complicated by multiple previous fractures, precocious puberty and thyrotoxicosis. The patient has remained well and is concerned about the risk of malignancy.

Which TWO malignancies is she most at risk of developing?

Breast carcinoma

Osteosarcoma

Lung carcinoma

Small bowel lymphoma

Colorectal carcinoma

Melanoma

Astrocytoma

Atrial myxoma

Hepatocellular carcinoma

Correct

McCune–Albright syndrome is due to a mutation in a G-protein. This results in a spectrum of polyostotic fibrous dysplasia, caféau- lait spots and endocrinopathies.

There is an increased risk of osteosarcoma and other connective tissue tumours, especially if the patient has had multiple radiographs of affected areas. With precocious puberty the patient is at increased risk of developing breast carcinoma.

Incorrect

McCune–Albright syndrome is due to a mutation in a G-protein. This results in a spectrum of polyostotic fibrous dysplasia, caféau- lait spots and endocrinopathies.

There is an increased risk of osteosarcoma and other connective tissue tumours, especially if the patient has had multiple radiographs of affected areas. With precocious puberty the patient is at increased risk of developing breast carcinoma.

Question 16 of 50

16. Question

A 44-year-old gentleman is referred to clinic with headaches and a raised fasting glucose. He has also noticed a change in his facial appearance and enlargement of his hands.

Examination reveals prognathism, enlarged digits and bitemporal hemianopia. A glucose tolerance test fails to suppress growth hormone levels. A magnetic resonance scan of the pituitary fossa reveals an adenoma. The patient does not wish for surgery

What THREE medical therapies can be offered to the patient to treat the underlying disease?

17. Question

A 33-year-old female auxillary nurse presents for review. She has had difficult in managing hypertension and is currently taking atenolol 100 mg and ramipril 10 mg, yet her blood pressure is still raised at 165/80 mmHg. On examination she has a body mass index (BMI) of 32.

Fasting blood results reveal:

Na+ 140 mmol/l

K+ 2.8 mmol/l

HCO3 – 40 mmol/l

Glucose 7.8 mmol/l

Which of the following is the next investigation of choice here?

Renin/aldosterone levels with antihypertensive medication discontinued for around 3 weeks

Renal ultrasound scan

Computed tomography (CT) scan of the abdomen

Renin/aldosterone levels on therapy

Renin/aldosterone levels with antihypertensive medication discontinued for 2 days

Correct

The best test for Conn’s syndrome from this list would be renin/aldosterone levels with antihypertensive medication having been discontinued for around 3 weeks. This is because the pre-existing antihypertensives would affect the renin/aldosterone ratio.

Incorrect

The best test for Conn’s syndrome from this list would be renin/aldosterone levels with antihypertensive medication having been discontinued for around 3 weeks. This is because the pre-existing antihypertensives would affect the renin/aldosterone ratio.

Question 18 of 50

18. Question

A 42-year-old woman is referred with difficult to treat hypertension. She is currently taking ramipril 10 mg daily and bendrofluazide 2.5 mg daily yet recent blood pressure was 165/90 mmHg. Past medical history in the family of subarachnoid haemorrhage was noted. She is currently being treated with amytriptyline for depression.

Circulating calcitonin levels are elevated. Examination in the clinic reveals a patient of normal body habitus, with a blood pressure of 170/90 mmHg.

Which of the following is the most appropriate treatment for her blood pressure prior to surgery?

Phenoxybenzamine

Propanolol

Doxasosin

Prazosin

Atenolol

Correct

This patient has difficult hypertension and raised calcitonin levels. The suspicion is that she has MEN-2a with medullary thyroid carcinoma and phaeochromocytoma .phenoxybenzamine is commonly used for the 3 days prior to surgery to ensure complete alpha blockade.

Incorrect

This patient has difficult hypertension and raised calcitonin levels. The suspicion is that she has MEN-2a with medullary thyroid carcinoma and phaeochromocytoma .phenoxybenzamine is commonly used for the 3 days prior to surgery to ensure complete alpha blockade.

Question 19 of 50

19. Question

A 54-year-old Asian man with a 10-year history of type 2 diabetes has been diagnosed with background diabetic retinopathy at his annual review. He is taking gliclazide 80 mg bd as he failed to tolerate metformin.

Which of the following is the most appropriate additional therapy to reduce progression of his renal disease and impact on cardiovascular risk?

Ramipril

Insulin

Simvastatin

Fenofibrate

Additional 160 mg of gliclazide per day

Correct

This man may receive additional protection against microvascular disease by achieving Hb A1c target of 7% with increasing gliclazide dose or transitioning to insulin, but use of insulin or sulphonylureas in the UKPDS study was not associated with improvements in cardiovascular mortality.

In contrast, the HOPE study demonstrated that ramipril has positive effects on cardiovascular mortality in diabetic patients and the angiotensin-converting enzyme (ACE) inhibitor class have proven effects on progression of albuminuria in diabetes.

Incorrect

This man may receive additional protection against microvascular disease by achieving Hb A1c target of 7% with increasing gliclazide dose or transitioning to insulin, but use of insulin or sulphonylureas in the UKPDS study was not associated with improvements in cardiovascular mortality.

In contrast, the HOPE study demonstrated that ramipril has positive effects on cardiovascular mortality in diabetic patients and the angiotensin-converting enzyme (ACE) inhibitor class have proven effects on progression of albuminuria in diabetes.

Question 20 of 50

20. Question

A young female junior doctor is concerned that she has put on weight since she was a medical student, as she now no longer finds time to exercise. She looks in the British National Formulary for drugs that cause weight loss and decides to try some on a temporary basis.

After 2 months, she is successfully losing weight but also has trouble with increased stool frequency. However, she is concerned, as she has also noticed difficulty in climbing stairs. She has no problems walking on the flat, but she also has difficulty getting up out of chairs.

She has difficulty in sleeping at the moment but puts that down to increased frequency of headaches for the past 2 months. She asks you, a fellow work colleague, what the cause of her weakness could be.

Her weakness fits with a proximal muscle weakness, which can be caused by hyperthyroidism. She may also be tachycardic but has not experienced palpitations.

Metformin can cause diarrhoea and headaches but does not cause muscle weakness.

Question 21 of 50

21. Question

You see a new patient in a diabetic clinic who was started on metformin 3 years ago. His weight is maintained at around 70 kg. His GP has carried out some routine blood tests including his Hb A1c. The patient has a history of ischaemic heart disease and heart failure, hypertension and moderate renal impairment.

He has very poor control of his diabetes with possible end organ damage. He already has moderate renal impairment, so both metformin and sulfonylureas are contraindicated unless the patient is unable to use insulin. Rosiglitazone is only indicated as second-line therapy if the sulfonylureas are contraindicated as in this case, but rosiglitazone is contraindicated in heart failure.

Incorrect

He has very poor control of his diabetes with possible end organ damage. He already has moderate renal impairment, so both metformin and sulfonylureas are contraindicated unless the patient is unable to use insulin. Rosiglitazone is only indicated as second-line therapy if the sulfonylureas are contraindicated as in this case, but rosiglitazone is contraindicated in heart failure.

Question 22 of 50

22. Question

A 55-year-old man presents to his GP complaining of a cough and breathlessness that has been present for about 2 weeks. He reports that prior to the onset of these symptoms, he was fit and well and was not on any medication. He is a known smoker of 10 cigarettes per day and has been smoking for over 25 years.

On examination, the GP was unable to elicit any positive clinical signs and diagnosed a mild viral chest infection and reassured the patient that the symptoms would settle of their own accord. Two weeks later, the patient then presented again to the GP, this time complaining of thirst, polyuria and generalised muscle weakness. The GP noticed the presence of ankle oedema.

A prick test confirmed the presence of hyperglycaemia and the patient was referred to the hospital for investigations where the medical registrar ordered a variety of blood tests.

Some of these results are shown below:

Na 144 mmol/l

K 2.2 mmol/l

Bicarbonate 34 mmol/l

Glucose 16 mmol/l

What is the most likely diagnosis?

Ectopic ACTH production

Acromegally

Cushing’s syndrome

Conn’s syndrome

Addison’s syndrome

Correct

This patient has a small (oat) cell carcinoma of the lung which is a rapidly growing aggressive tumour characterised by early spread to distant sites. Patients often present with disseminated disease.

A feature of this tumour is the range of paraneoplastic syndromes that occur due to the production of a variety of peptide hormones, the most common of which are the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and the syndrome of ectopic adrenocorticotropin hormone (ACTH) production.

Typical features of Cushing’s syndrome are often absent in these patients but they may present with pigmentation and weight loss accompanied by hyperglycaemia, hypokalaemia, a metabolic alkalosis and increased serum and urine cortisol concentrations.

Incorrect

This patient has a small (oat) cell carcinoma of the lung which is a rapidly growing aggressive tumour characterised by early spread to distant sites. Patients often present with disseminated disease.

A feature of this tumour is the range of paraneoplastic syndromes that occur due to the production of a variety of peptide hormones, the most common of which are the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and the syndrome of ectopic adrenocorticotropin hormone (ACTH) production.

Typical features of Cushing’s syndrome are often absent in these patients but they may present with pigmentation and weight loss accompanied by hyperglycaemia, hypokalaemia, a metabolic alkalosis and increased serum and urine cortisol concentrations.

Question 23 of 50

23. Question

A 58-year-old man with type 2 diabetes complains of visual distortion when he is reviewed at his annual appointment. You examine his retinal photographs and in the left eye there is evidence of background diabetic retinopathy.

On examination of the right retinal photograph you see a number of small haemorrhages and evidence of hard exudates within one disc diameter of the macula.

Which of the following is the most appropriate plan of management for this patient?

Early referral for ophthalmology review within 6 weeks

Immediate referral for ophthalmology review

Routine ophthalmology referral

Repeat retinal photographs in 6 months

Repeat retinal photographs at 1 year

Correct

This man has maculopathy affecting the right eye. This necessitates early review by an ophthalmologist for consideration of laser therapy, usually within a 6 week period.

Incorrect

This man has maculopathy affecting the right eye. This necessitates early review by an ophthalmologist for consideration of laser therapy, usually within a 6 week period.

Question 24 of 50

24. Question

A 42-year-old female patient is referred to clinic with palpitations. Approximately 3 weeks ago she had suffered with the flu and since then she has been getting occasional palpitations, anxiety attacks and loose bowel motions. Her weight has remained stable and she has previously been fit and well.

Examination reveals a tender thyroid, but no enlargement or focal masses. Her pulse rate is 110/min and regular.

Thyroid function tests reveal:

Thyroid-stimulating hormone(TSH) 0.3 mU/l (0.4–5 mU/l)

Thyroxine (T4) 190 nmol/l (58–174 nmol/l)

Tri-iodothyronine (T3) 3.21 nmol/l (1.07 – 3.18 nmol/l)

Erythrocyte sedimentation rate 45 mm/1st hour (<20 mm/1st hour)

What are the TWO next best management steps?

Ibuprofen

Propanolol

Carbimazole

Propylthiouracil

Radioiodine

Subtotal thyroidectomy

Lugol’s iodine

Prednisolone

Correct

De Quervain’s thyroiditis is transient inflammation of the thyroid, which typically occurs in females in the fourth and fifth decade. Patients can have a preceding viral infection followed by mild symptoms of hyperthyroidism. The thyroid gland is usually tender by this time. If bloods are taken early the patient can display a low thyroid-stimulating hormone (TSH) and raised thyroxine (T4)/tri-iodothyronine (T3).

Treatment includes management of symptoms with beta-blockers and nonsteroidal anti-inflammatory drugs (NSAIDS). Prednisolone can be used if NSAIDS are ineffective.

The symptoms should resolve but can take weeks to a few months to do so, and the patient’s thyroid status should be monitored. Some patients are left hypothyroid after the inflammation has settled.

Incorrect

De Quervain’s thyroiditis is transient inflammation of the thyroid, which typically occurs in females in the fourth and fifth decade. Patients can have a preceding viral infection followed by mild symptoms of hyperthyroidism. The thyroid gland is usually tender by this time. If bloods are taken early the patient can display a low thyroid-stimulating hormone (TSH) and raised thyroxine (T4)/tri-iodothyronine (T3).

Treatment includes management of symptoms with beta-blockers and nonsteroidal anti-inflammatory drugs (NSAIDS). Prednisolone can be used if NSAIDS are ineffective.

The symptoms should resolve but can take weeks to a few months to do so, and the patient’s thyroid status should be monitored. Some patients are left hypothyroid after the inflammation has settled.

Question 25 of 50

25. Question

A 65-year-old woman is brought into hospital moribund. Her relatives state she has been increasingly lethargic over the past month and had put on weight. She had been slightly confused with constipation and was commenced on antibiotics for a presumed urinary tract infection. She currently takes no regular medication.

Myxoedema coma can be the presentation of hypothyroidism, but usually occurs on a background of long-standing hypothyroidism. Patients will have a history of cold intolerance, weight gain, increasing lethargy, and constipation.

This is an emergency and treatment involves intravenous thyroxine and slow rewarming. It is also important to take serum for thyroid function and adrenal function.

Coexisting hypoadrenalism is suggested by hypoglycaemia, hyperkalaemia, and a raised urea. Treatment with hydrocortisone is recommended till Addison’s disease can be excluded.

Incorrect

Myxoedema coma can be the presentation of hypothyroidism, but usually occurs on a background of long-standing hypothyroidism. Patients will have a history of cold intolerance, weight gain, increasing lethargy, and constipation.

This is an emergency and treatment involves intravenous thyroxine and slow rewarming. It is also important to take serum for thyroid function and adrenal function.

Coexisting hypoadrenalism is suggested by hypoglycaemia, hyperkalaemia, and a raised urea. Treatment with hydrocortisone is recommended till Addison’s disease can be excluded.

Question 26 of 50

26. Question

A 56-year-old woman was admitted to the intensive therapy unit (ITU) after a road traffic accident. She required mechanical ventilation and treatment for hypertension. She was obese and had a small firm goitre.

Results obtained 6 days after admission showed:

Free thyroxine (T4) 4.1 pmol/l (10–22)

Free tri-iodothyronine (T3) 1.5 pmol/l (5–10)

Thyroid-stimulating hormone (TSH) 0.5 mU/l (0.4–5)

Which of the following is the most appropriate management of her thyroid disorder?

Repeat thyroid function testing in 3 months

Thyroxine 50 ىg/ day

Thyroxine 100 ىg/ day

Carbimazole

Propylthiouracil

Correct

This patient has a normal thyroid-stimulating hormone (TSH) level, which suggests that she is suffering from ‘sick-euthyroid’ syndrome. This condition, characterised by low tri-iodothyonine (T3) and thyroxine (T4) and normal TSH, is associated with severe illness and frequently occurs in patients admitted to the intensive therapy unit.

Most physicians advise repeating thyroid function testing in a few months .

Incorrect

This patient has a normal thyroid-stimulating hormone (TSH) level, which suggests that she is suffering from ‘sick-euthyroid’ syndrome. This condition, characterised by low tri-iodothyonine (T3) and thyroxine (T4) and normal TSH, is associated with severe illness and frequently occurs in patients admitted to the intensive therapy unit.

Most physicians advise repeating thyroid function testing in a few months .

Question 27 of 50

27. Question

A 26-year-old dancer is referred by her dentist since he was concerned about the erosion of enamel on her teeth. The patient herself reports no health problems, and feels generally fit and well, admitting to exercising for 3 hours every day.

However, examination of the patient shows her to be thin and she is found to weigh 48 kg but is 1.7 m tall. Routine laboratory investigations are performed.

Which of the following laboratory results is NOT compatible with the suspected diagnosis?

Serum amylase 47 U/l

Potassium 2.2 mmol/l

Sodium 132 mmol/l

Bicarbonate 35 mmol/l

Serum calcium levels 1.9 mmol/l

Correct

Anorexia nervosa laboratory studies that support the diagnosis include a normocytic normochromic anaemia due to bone marrow suppression, hypokalaemia from laxative abuse, metabolic alkalosis resulting from vomiting and the gastrointestinal loss of HCl, hypocalcaemia from dietary deficiency and the associated protein deficiency, and increased serum amylase level from frequent vomiting.

Incorrect

Anorexia nervosa laboratory studies that support the diagnosis include a normocytic normochromic anaemia due to bone marrow suppression, hypokalaemia from laxative abuse, metabolic alkalosis resulting from vomiting and the gastrointestinal loss of HCl, hypocalcaemia from dietary deficiency and the associated protein deficiency, and increased serum amylase level from frequent vomiting.

28. Question

Cholesterol on admission was 10.5 mmol/l with relatively normal triglycerides and a marked increase in LDL.

Which of the following is the most likely diagnosis in this case?

Familial hypercholesterolaemia

Familial hypertriglyceridaemia

Familial hyperalphalipoproteinaemia

Familial lipoprotein lipase deficiency

Alcohol excess leading to lipoprotein abnormalities

Correct

Familial hypercholesterolaemia (FH) has an incidence of 1:500 and is inherited in autosomal dominant fashion. It is due to a defect in the LDL receptor, which results in elevated serum cholesterol and relatively normal triglycerides.

Familial hypercholesterolaemia (FH) has an incidence of 1:500 and is inherited in autosomal dominant fashion. It is due to a defect in the LDL receptor, which results in elevated serum cholesterol and relatively normal triglycerides.

29. Question

A 28-year-old single woman presents to the endocrine clinic with recent symptoms of sweating, weight loss and palpitations. On examination she has a BMI of 20, there is no palpable goitre and a tremor is noted.

Investigations:

TSH <0.05 mU/l (0.5–4)

Free T4 32.1 pmol/l (10–22)

Thyroid scintography revealed decreased uptake

Which of the following is the most appropriate next investigation?

Thyroglobulin levels

Abdominal ultrasound scan

Thyroid ultrasound scan

Fine needle aspiration biopsy

Beta HCG

Correct

One possible cause of recent-onset thyrotoxicosis is thyroiditis. Thyroglobulin levels can be used to differentiate thyroiditis and other causes of hyperthyroidism from thyrotoxicosis factitia.

Incorrect

One possible cause of recent-onset thyrotoxicosis is thyroiditis. Thyroglobulin levels can be used to differentiate thyroiditis and other causes of hyperthyroidism from thyrotoxicosis factitia.

Question 30 of 50

30. Question

A 28-year-old woman attends the endocrine clinic because of inability to achieve a pregnancy. She and her husband have been trying for some 3 years for a child without success.

Her general practitioner (GP) has measured a prolactin level of 2600 mU/l (normal <360). You arrange pituitary magnetic resonance imaging (MRI) that demonstrates a microprolactinoma. She elects for pharmacotherapy.

Which two of the following agents may be appropriate treatment choices?

Carbergoline

Methyldopa

Haloperidol

Thioridazine

Domperidone

Correct

Cabergoline is an ergot-derived long-acting dopamine agonist, which is taken once or twice per week. Mechanism of action is activation of the D2 receptors.

Side-effects that occur commonly at treatment initiation include nausea and postural hypotension. Rarely, patients have been known to develop hallucinations and psychosis, but this is only at very high drug doses.

It is important to warn female patients that, within a few months, menstrual cycles are likely to return, and that pregnancy has a much higher probability.

Although cabergoline is not licensed in pregnancy and bromocriptine is, neither drug has so far been associated with birth defects.

Incorrect

Cabergoline is an ergot-derived long-acting dopamine agonist, which is taken once or twice per week. Mechanism of action is activation of the D2 receptors.

Side-effects that occur commonly at treatment initiation include nausea and postural hypotension. Rarely, patients have been known to develop hallucinations and psychosis, but this is only at very high drug doses.

It is important to warn female patients that, within a few months, menstrual cycles are likely to return, and that pregnancy has a much higher probability.

Although cabergoline is not licensed in pregnancy and bromocriptine is, neither drug has so far been associated with birth defects.

Question 31 of 50

31. Question

A 64-year-old type 2 diabetes patient presents for review. She has poor blood glucose control and is taking maximal doses of metformin and gliclazide. You elect to substitute insulin glargine for her gliclazide.

Which of the following options best describes the amino acid modifications seen in glargine insulin?

Glycine is at position A21, two arginines are added to the B chain

Aspartic acid is at position B28

Glycine is at position B28

Aspartic acid is at position A21

Proline is at position A21

Correct

The clue is in the name, ‘glargine’ is an amalgam of glycine and arginine. Insulin glargine is a long-acting insulin analogue. It has recently been joined by another insulin analogue, insulin detemir. Insulin aspart is a short-acting insulin analogue which has an aspartic acid residue at position B28.

The main use for insulin analogues is in improving glycaemic control in type 1 diabetes. Some patients may be limited in haemoglobin A1c (HbA1c) reductions due to post-meal hypoglycaemia or nocturnal hypoglycaemia, and the use of short- and/or long-acting insulin analogues may improve glycaemic control with reduced incidence of hypoglycaemia compared to conventional insulins.

Incorrect

The clue is in the name, ‘glargine’ is an amalgam of glycine and arginine. Insulin glargine is a long-acting insulin analogue. It has recently been joined by another insulin analogue, insulin detemir. Insulin aspart is a short-acting insulin analogue which has an aspartic acid residue at position B28.

The main use for insulin analogues is in improving glycaemic control in type 1 diabetes. Some patients may be limited in haemoglobin A1c (HbA1c) reductions due to post-meal hypoglycaemia or nocturnal hypoglycaemia, and the use of short- and/or long-acting insulin analogues may improve glycaemic control with reduced incidence of hypoglycaemia compared to conventional insulins.

Question 32 of 50

32. Question

A 40-year-old man presents to the hypertension clinic with difficult to control blood pressure. He is now taking ramipril 10 mg daily and amlodipine 10 mg, but his blood pressure is still 153/88 mmHg.

Blood tests reveal:

Sodium 145 mmol/l

Potassium 3.0 mmol/l

Urea 5.2 mmol/l

Creatinine 85 ىmol/l

Renal ultrasound scan normal sized kidneys

Which of the following represents the best investigation for this patient?

Plasma renin, aldosterone and cortisol level after washout of antihypertensives

Plasma renin, aldosterone and cortisol level

Echocardiogram

Renal angiogram

Oral salt loading

Correct

ACE inhibitors may increase plasma renin activity, and calcium antagonists may reduce aldosterone. Hence, renin, aldosterone and cortisol should be measured after a 2-week washout period to confirm primary hyperaldosteronism, the most likely diagnosis here.

Incorrect

ACE inhibitors may increase plasma renin activity, and calcium antagonists may reduce aldosterone. Hence, renin, aldosterone and cortisol should be measured after a 2-week washout period to confirm primary hyperaldosteronism, the most likely diagnosis here.

Question 33 of 50

33. Question

A 32-year-old lady presents with headaches, anxiety, and palpitations. She states that members of her family on her father’s side have had similar symptoms and have required operations.

She has elevated urinary metanephrines. The consultant is concerned about the possibility of multiple endocrine neoplasia (MEN) type 2.

34. Question

A 31-year-old woman who works in a pharmacy comes to the clinic for review. Over the past few months she has lost increasing amounts of weight and has become increasingly anxious about palpitations, which particularly occur at night. Her GP has measured a TSH which is <0.1 IU/l (0.5-4.5).

On examination her BP is 122/72 mmHg, her pulse is 92 and regular. You cannot palpate goitre or any nodules on examination of her neck.

Which of the following investigations is likely most to differentiate between self administration of thyroid hormone and endogenous causes of thyrotoxicosis?

35. Question

A 71-year-old woman who is taking long term amiodarone therapy for paroxysmal AF comes to the clinic for review. She has been complaining of increasing palpitations, weight loss and heat intolerance over the past few months.

On examination her BP is 149/89 mmHg, pulse is 85 and regular. She is sweaty and has a tremor. A TSH is measured at 0.1 IU/l.

Which of the following is most likely to differentiate between AIT type 1 and type 2?

Colour flow Doppler of the thyroid

Free T3

Interleukin 1

Interleukin 6

Thyroid binding globulin

Correct

Type 2 AIT is an autoimmune thyroiditis. Colour flow Doppler has been investigated as a tool to differentiate type 1 and type 2 AIT in a number of studies including the one referenced below. It appears to be superior to IL-6.

Incorrect

Type 2 AIT is an autoimmune thyroiditis. Colour flow Doppler has been investigated as a tool to differentiate type 1 and type 2 AIT in a number of studies including the one referenced below. It appears to be superior to IL-6.

Question 36 of 50

36. Question

A 42-year-old woman with a history of Graves’ disease currently managed with a block replace regimen comes to the clinic for review; she is some four months into her treatment. On this occasion her main complaint is of a rash on both shins; it is not particularly painful, more unsightly.

On examination her BP is 135/72 mmHg, pulse is 78 and regular. You notice mild proptosis consistent with Graves’ eye disease, and a rash over both tibiae which is raised, indurated and discoloured.

Investigations show:

Hb 13.7 g/dl (11.5-16.0)

WCC 9.9 x109/l (4-11)

PLT 203×109/l (150-400)

Na 138 mmol/l (135-146)

K 3.9 mmol/l (3.5-5.0)

Cr 100 micromol/l (79-118)

TSH 1.2 IU/l (0.5-4.5)

Which of the following would be the most appropriate way to manage her rash?

Reassurance

Topical fluocinolone

Oral azathioprine

Oral cyclosporin

Oral prednisolone

Correct

This patient has pretibial myxoedema, with the rash on her shins representing the typical appearance for this. No treatment is usually required, although when there is more severe localised pain, then patients may be considered for local use of a potent corticosteroid such as fluocinolone. Only very rarely are systemic corticosteroids instigated.

Incorrect

This patient has pretibial myxoedema, with the rash on her shins representing the typical appearance for this. No treatment is usually required, although when there is more severe localised pain, then patients may be considered for local use of a potent corticosteroid such as fluocinolone. Only very rarely are systemic corticosteroids instigated.

Question 37 of 50

37. Question

A 67-year-old woman presents to the diabetes clinic. She has recently sustained a left Colles fracture and you suspect underlying osteoporosis. Current medication includes metformin, pioglitazone, BD mixed insulin, ramipril, indapamide and amlodipine. On examination her BP is 145/72 mmHg, pulse is 78 and regular. Her BMI is 32.

Investigations show:

Hb 12.9 g/dl (11.5-16.0)

WCC 6.2×109/l (4-11)

PLT 188×109/l (150-400)

Na 137 mmol/l (135-146)

K 4.9 mmol/l (3.5-5.0)

Cr 123 micromol/l (79-118)

Ca 2.56 mmol/l (2.20-2.61)

Which of her medications is most likely to be linked to risk of osteoporotic fracture?

Pioglitazone

Ramipril

Indapamide

Insulin

Metformin

Correct

It is recognised that long term use of glitazone therapy increases the risk of osteoporotic fracture. The underlying mechanism is thought to be due to bone cell precursors differentiating into adipocytes rather than osteoblasts.

Incorrect

It is recognised that long term use of glitazone therapy increases the risk of osteoporotic fracture. The underlying mechanism is thought to be due to bone cell precursors differentiating into adipocytes rather than osteoblasts.

Question 38 of 50

38. Question

A 62-year-old man presents to the diabetes clinic for review. His current diabetes medication includes metformin and pioglitazone. Past history of note includes transurethral resection of bladder tumours some three years earlier.

On examination his BP is 142/82 mmHg, pulse is 75 and regular, his BMI is 31. Respiratory and abdominal examination is unremarkable.

Investigations show:

Hb 13.4 g/dl (13.5-17.7)

WCC 7.1×109/l (4-11)

PLT 170×109/l (150-400)

Na 138 mmol/l (135-146)

K 4.9 mmol/l (3.5-5.0)

Cr 129 micromol/l (79-118)

HbA1c 7.6% (<5.5)

Which of the following is the most appropriate way to manage his diabetes?

Stop pioglitazone and substitute an alternative

Add BD mixed insulin

Add liraglutide

Add sitagliptin

Continue current therapy

Correct

Recent guidance suggests that pioglitazone should be discontinued in patients with macroscopic haematuria or those with a history of or a current diagnosis of carcinoma of the bladder.

This is because a small but statistically significant signal for increased risk of bladder cancer in patients taking pioglitazone has been revealed.

Incorrect

Recent guidance suggests that pioglitazone should be discontinued in patients with macroscopic haematuria or those with a history of or a current diagnosis of carcinoma of the bladder.

This is because a small but statistically significant signal for increased risk of bladder cancer in patients taking pioglitazone has been revealed.

Question 39 of 50

39. Question

A 53-year-old South Asian woman presents to the clinic complaining of generalised aches and pains. She has been living in the United Kingdom for many years, follows a vegetarian diet and rarely goes out of the house. Medication includes metformin which she takes for recently diagnosed type 2 diabetes.

On examination her BP is 155/82 mmHg, she has generalised bony aches and pains, worse over her back and hips. Her BMI is 28.

40. Question

A 56-year-old woman is referred to the endocrine clinic with lethargy, weight gain and hair loss. Her problems have become worse over the past three to six months. Past history of note includes hypertension for which she takes indapamide.

On examination her pulse is 66 and regular and BP is 152/88 mmHg. Her BMI is 31. She has obvious generalised thinning of her hair.

Investigations show:

Haemoglobin 11.7 g/dl (11.5-16.0)

White cell count 7.0 x 109/l (4-11)

Platelets 186 x 109/l (150-400)

Sodium 136 mmol/l (135-146)

Potassium 4.0 mmol/l (3.5-5)

Creatinine 100 micromol/l (79-118)

TSH 9.8 IU (0.5-5)

Which of the following lipid abnormalities would you most expect to find?

Increased triglycerides

Low overall LDL

Decreased IDL

Increased HDL

Increased large LDL particles

Correct

The predominant picture in hypothyroidism is mixed dyslipidaemia so the only possible correct answer is increased triglycerides.

Incorrect

The predominant picture in hypothyroidism is mixed dyslipidaemia so the only possible correct answer is increased triglycerides.

Question 41 of 50

41. Question

A 39-year-old woman with a history of Graves’ disease comes to the Emergency department complaining of bilateral blurring of vision and loss of colour perception.

On examination she has obvious bilateral thyroid eye disease with marked proptosis. She is currently managed on a block replace regime to control her thyroid function.

Which of the following is the most appropriate way to manage her eye disease?

High dose corticosteroids

Methotrexate

Orbital radiotherapy

Surgical decompression

Azathioprine

Correct

This patient has symptoms consistent with acute progressive optic neuropathy which occurs due to stretching of the optic nerve. Other features include reduced visual acuity, a visual field defect and a relative afferent papillary defect.

Azathioprine and methotrexate are steroid sparing agents used in the management of thyroid eye disease, but it is high dose corticosteroids which are used first line.

Orbital decompression surgery may be used in the acute situation when the response to corticosteroids is not adequate.

Incorrect

This patient has symptoms consistent with acute progressive optic neuropathy which occurs due to stretching of the optic nerve. Other features include reduced visual acuity, a visual field defect and a relative afferent papillary defect.

Azathioprine and methotrexate are steroid sparing agents used in the management of thyroid eye disease, but it is high dose corticosteroids which are used first line.

Orbital decompression surgery may be used in the acute situation when the response to corticosteroids is not adequate.

Question 42 of 50

42. Question

A 54-year-old man with a three year history of type 2 diabetes comes to the clinic for review. He is currently managed with metformin 1 g BD and feels that his home blood glucose monitoring has deteriorated over the past few months. There is also a past history of hypertension and dyslipidaemia for which he takes ramipril 10 mg daily and atorvastatin 20 mg.

On examination his BP is 155/82 mmHg, pulse is 71 and regular. His chest is clear. He is obese with a BMI of 32.

Investigations show:

Haemoglobin 12.9 g/dl (13.5 – 17.7)

White cell count 5.0 x109/l (4 – 11)

Platelets 180 x109/l (150 – 400)

Sodium 140 mmol/l (135 – 146)

Potassium 5.0 mmol/l (3.5 – 5)

Creatinine 123 mmol/l (79 – 118)

HbA1c 8.0% (<7.0)

He would like to commence sitagliptin.

Which of the following adverse effects would you warn him about?

GI disturbance

Increased influenza risk

Osteoporosis

Significant hypoglycaemia

Weight gain

Correct

GI disturbance is reported across a range of sitagliptin studies, including nausea, flatulence, diarrhoea and constipation.

Increased influenza risk was reported in studies of sitagliptin in combination with insulin.

Incorrect

GI disturbance is reported across a range of sitagliptin studies, including nausea, flatulence, diarrhoea and constipation.

Increased influenza risk was reported in studies of sitagliptin in combination with insulin.

Question 43 of 50

43. Question

A 33-year-old female presents with a one year history of galactorrhoea and amenorrhoea. She informs you that she does not want to become pregnant.

On examination there is galactorrhoea to expression and visual fields are normal to confrontation.

Investigations confirm the diagnosis of a macroprolactinoma, with a prolactin concentration of 10,500 mu/l (50- 500) and MRI of the pituitary revealing a 1.5 cm tumour with some suprasellar extension.

What is the most appropriate treatment for this woman?

Cabergoline therapy

Combined oral contraceptive

Pituitary surgery

Somatostatin analogue therapy

Stereotactic pituitary irradiation

Correct

This young woman has a macroprolactinoma. These are exquisitely sensitive to dopamine agonist therapy and rapid tumour reduction with restoration of menses and cessation of galactorrhoea is expected.

Even with large tumours that compress the chiasm, these can be treated with dopamine agonists with rapid reduction in size and relief of pressure.

Pituitary surgery is rarely required in prolactinomas and is generally reserved for patients intolerant or resistant to dopamine agonist therapy.

Incorrect

This young woman has a macroprolactinoma. These are exquisitely sensitive to dopamine agonist therapy and rapid tumour reduction with restoration of menses and cessation of galactorrhoea is expected.

Even with large tumours that compress the chiasm, these can be treated with dopamine agonists with rapid reduction in size and relief of pressure.

Pituitary surgery is rarely required in prolactinomas and is generally reserved for patients intolerant or resistant to dopamine agonist therapy.

Question 44 of 50

44. Question

A 55-year-old man was diagnosed with atrial fibrillation and commenced on amiodarone two years ago. His thyroid function tests prior to commencing amiodarone were normal.

He subsequently developed hyperthyroidism whilst on amiodarone. Amiodarone was stopped four months ago and he was commenced on 40 mg carbimazole OD but he continued to lose weight despite maintaining a good appetite. His other medications comprised digoxin 250 micrograms OD and warfarin as per INR. There was no family history of thyroid disease.

On examination, pulse was 92 beats per minute, irregularly irregular, blood pressure was 130/70 mmHg. There was no goitre palpable on neck examination and he had no visible tremors.

In this scenario of amiodarone-induced thyroiditis with a low uptake scan suggesting the thyroiditis and type 2 amiodarone-induced thyrotoxicosis, the most appropriate treatment is withdrawal of the amiodarone and steroid therapy.

Incorrect

In this scenario of amiodarone-induced thyroiditis with a low uptake scan suggesting the thyroiditis and type 2 amiodarone-induced thyrotoxicosis, the most appropriate treatment is withdrawal of the amiodarone and steroid therapy.

Question 45 of 50

45. Question

A 43-year-old male presents with a six month history of tiredness, weight gain and poor concentration. Two years ago he underwent surgery for a non-functional pituitary tumour and has been receiving replacement therapy with hydrocortisone 10 mg bd, thyroxine 150 μg daily and testosterone 250 mg im monthly.

Investigations reveal:

Free T4 15.9 pmol/L (10-22)

TSH 0.5 mU/L (0.4-5)

Testosterone 17.2 nmol/L (10-30)

IGF-1 9.6 nmol/L (10-35)

Which of the following would be the most appropriate treatment for this man’s symptoms?

Growth hormone

Fludrocortisone

DDAVP

Increase dose of hydrocortisone

Reduce dose of thyroxine

Correct

This man appears to be panhypopituitary and is receiving adequate replacement therapy.

Symptoms of tiredness, poor concentration and weight gain suggest growth hormone (GH) deficiency and this is supported by the low IGF-1 concentration.

Incorrect

This man appears to be panhypopituitary and is receiving adequate replacement therapy.

Symptoms of tiredness, poor concentration and weight gain suggest growth hormone (GH) deficiency and this is supported by the low IGF-1 concentration.

Question 46 of 50

46. Question

A 15-year-old female presents with a six month history of secondary amenorrhoea. She has been otherwise well and has also noticed slight galactorrhoea over the last three months. She had menarche at the age of 12 and has otherwise had regular periods. She has been sexually active for approximately one year and has occasionally used condoms for contraception. She smokes five cigarettes daily and occasionally smokes cannabis.

On examination she appears well, appears clinically euthyroid, has a pulse of 70 bpm and a blood pressure of 112/70 mmHg.

Investigations show:

Serum oestradiol 130 nmol/L (130-600)

Serum LH 4.5 mU/L (2-20)

Serum FSH 2.2 mU/L (2-20)

Serum prolactin 6340 mU/L (50-450)

Free T4 7.2 pmol/L (10-22)

TSH 2.2 mU/L (0.4-5.0)

What is the most likely diagnosis?

Prolactinoma

Drug induced

Non-functional pituitary tumour

Polycystic ovarian syndrome

Pregnancy

Correct

This girl has hyperprolactinaemia and, in general, a prolactin above 2000 mU/L is suggestive of a prolactinoma rather than a non-functioning tumour with stalk compression.

Although hyperprolactinaemia is a feature, this is not pregnancy as elevated oestradiol concentrations would accompany the hyperprolactinaemia.

This level of hyperprolactinaemia would not be found in polycystic ovarian syndrome as concentrations are below 1000 and the oestradiol concentrations are high normal.

Incorrect

This girl has hyperprolactinaemia and, in general, a prolactin above 2000 mU/L is suggestive of a prolactinoma rather than a non-functioning tumour with stalk compression.

Although hyperprolactinaemia is a feature, this is not pregnancy as elevated oestradiol concentrations would accompany the hyperprolactinaemia.

This level of hyperprolactinaemia would not be found in polycystic ovarian syndrome as concentrations are below 1000 and the oestradiol concentrations are high normal.

Question 47 of 50

47. Question

A 52-year-old female presents with a six month history of weight loss and diarrhoea. Over this period she had lost approximately 10 kg in weight and was aware of watery diarrhoea three to four times daily. She was also aware of occasional flushes which she had experienced since the menopause at the age of 49 but had become more frequent of late.

She had previously been well with no other medical history. She took no medication. She was a non-smoker and drank approximately 12 units of alcohol weekly.

On examination, she had a reddish complexion and had a BMI of 24 kg/m2. She had a pulse of 88 beats per minute regular and a blood pressure of 122/88 mmHg. There were no abnormalities on cardiovascular or respiratory examination but abdominal examination revealed two finger breadth hepatomegaly.

This patient has carcinoid syndrome as revealed by the grossly elevated urine 5 HIAA concentrations.

The best treatment for symptoms of carcinoid is the somatostatin analogue, octreotide, which improves symptoms and prognosis in carcinoid syndrome.

Incorrect

This patient has carcinoid syndrome as revealed by the grossly elevated urine 5 HIAA concentrations.

The best treatment for symptoms of carcinoid is the somatostatin analogue, octreotide, which improves symptoms and prognosis in carcinoid syndrome.

Question 48 of 50

48. Question

A 15-year-old girl is referred by her general practitioner with agitation and weight gain. Her mother accompanies her during the consultation and explains that over the last two months she has become increasingly agitated with poor sleep. Her progress at school has up until recently, been fine, although of late she has been apathetic. She has no past medical history of note.

Examination reveals no specific abnormalities with a blood pressure of 112/70 mmHg and a BMI of 20.

Her GP’s letter reveals the following results:

TSH 3.2 mU/L (0.4-5.0)

Total T4 250 nmol/L (55-144)

Free T4 12.9 pmol/L (10-22)

Total T3 3.2 nmol/L (0.9-2.8)

Free T3 6.8 pmol/L (5-10)

What is the likely diagnosis?

Pregnancy

Anorexia nervosa

Apathetic thyrotoxicosis

Laboratory error

Secondary hyperthyroidism

Correct

This patient has a good story of something going awry in the last two months and with normal thyroid function except for the elevated total T4 and T3 concentrations reflecting increased hormone binding, the suggested diagnosis is pregnancy.

Incorrect

This patient has a good story of something going awry in the last two months and with normal thyroid function except for the elevated total T4 and T3 concentrations reflecting increased hormone binding, the suggested diagnosis is pregnancy.

Question 49 of 50

49. Question

A 78-year-old male presents with exertional shortness of breath and palpitations. His symptoms developed over the last 24 hours. Previously he was active but was diagnosed with angina two years ago for which he takes isosorbide mononitrate 60 mg daily, atorvastatin 10 mg daily, diltiazem 200 mg daily and aspirin 75 mg daily. Two months ago he presented to his GP with general apathy and was commenced on fluoxetine 20 mg daily.

On examination he was noted to have a heart rate of 122 beats per minute irregularly irregular, a blood pressure of 120/80 mmHg but otherwise appears fine. In particular he appeared clinically euthyroid and no goitre was palpable on examination. ECG confirmed atrial fibrillation.

Investigations reveal:

Serum free T4 26.5 pmol/L (10-22)

Serum free T3 4.8 pmol/L (5-10)

Serum TSH 0.1 mU/L (0.4-5.0)

Thyroid autoantibodies Negative

ESR (Westergren) 28 mm/1st hr (0-10)

What is the likely cause of his abnormal thyroid function tests?

Solitary toxic thyroid nodule

DeQuervain's thyroiditis

Drug-induced thyrotoxicosis

Graves' disease

Hashimoto’s toxicosis

Correct

This patient has mild thyrotoxicosis as reflected by the raised T4 and low TSH but normal T3 and his prior symptoms of apathy probably relate to this.

In the absence of any thyroid auto-antibodies which argue against both Graves’ disease and hashitoxicosis, the most likely diagnosis is a solitary toxic nodule.

DeQuervain’s is associated with a tender goitre, weight loss and general malaise. A markedly raised ESR (>50 and usually 100) is typical. This man’s ESR would be considered reasonable for his age.

Incorrect

This patient has mild thyrotoxicosis as reflected by the raised T4 and low TSH but normal T3 and his prior symptoms of apathy probably relate to this.

In the absence of any thyroid auto-antibodies which argue against both Graves’ disease and hashitoxicosis, the most likely diagnosis is a solitary toxic nodule.

DeQuervain’s is associated with a tender goitre, weight loss and general malaise. A markedly raised ESR (>50 and usually 100) is typical. This man’s ESR would be considered reasonable for his age.

Question 50 of 50

50. Question

A 62-year-old woman is referred to you with persistent hypertension and obesity. She also complains of excessive pigmentation and headaches.

Her past medical history includes investigation in the 1970s for obesity, mild diabetes mellitus and hypertension. At that time, she had a bilateral adrenalectomy which was then the treatment of choice for her condition. Since then, she has been on hydrocortisone and fludrocortisone treatment.

On examination, she is noted to have hyperpigmentation and striae. BP was 175/100 mmHg. No abnormality of the visual fields is noted.

What is the likely diagnosis in this case?

Nelson’s syndrome

Phaeochromocytoma

Acromegaly

Addison’s disease

Conn’s syndrome

Correct

Nelson’s syndrome occurs in approximately 30% of patients adrenalectomised for Cushing’s disease. It is probably due to the clinical progression of the pre-existing pituitary adenoma after the restraint of hypercortisolism on adrenocorticotropic hormone (ACTH) secretion is removed.

Nelson’s syndrome occurs in approximately 30% of patients adrenalectomised for Cushing’s disease. It is probably due to the clinical progression of the pre-existing pituitary adenoma after the restraint of hypercortisolism on adrenocorticotropic hormone (ACTH) secretion is removed.